An observational study of antipsychotic medication use among long-stay nursing home residents without qualifying diagnoses.

WHAT IS KNOWN ON THE SUBJECT?: In the United States, 15.5% of nursing home residents without qualifying diagnoses of schizophrenia, Huntington's' Disease, and/or Tourette Syndrome receive antipsychotic medications. Antipsychotic medications are used off-label (i.e., used in a manner the United States Food and Drug Administration's packaging insert does not specify) to treat neuropsychiatric symptoms, often before attempting nonpharmacologic interventions, despite evidence that this drug class is associated with significant adverse events including death. Less than optimal staffing resources and lack of access to geropsychiatric specialists are barriers to reducing antipsychotic use. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: Antipsychotic use occurred in 11.6% of nursing home residents without qualifying or potentially qualifying diagnoses (bipolar disorder and psychotic disorder); antipsychotic use was more prevalent in residents with a dementia diagnosis than those without. One additional registered nurse hour per resident day could reduce the odds of antipsychotic use by 52% and 56% for residents with and without a dementia diagnosis respectively. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Given the influence of total staffing and professional staff mix on risk of antipsychotic use, nursing home administrators may want to consider aspects of facility operation that impact antipsychotic use. More stringent Unites States' survey and certification standards for dementia care implemented in 2017 demand proactive person-centered care that promotes maximal well-being and functioning without risk of harm from inappropriate psychoactive medications. Mental health nurses have requisite training to provide expert person-centered care to nursing home residents with mental illness and geropsychiatric disorders. ABSTRACT: Introduction Antipsychotic use in nursing homes varies widely across the United States; inadequate staffing, skill mix, and geropsychiatric training impede sustained improvement. Aim This study identified risk factors of antipsychotic use in long-stay residents lacking qualifying or potentially qualifying diagnoses. Method This secondary analysis used 2015 Minimum Data Set and cost report data from 458 Missouri nursing homes. The full sample (N = 29,679) was split into two subsamples: residents with (N = 15,114) and without (N = 14,565) a dementia diagnosis. Separate logistic regression models were run. Results Almost 15% of the dementia subsample and 8.4% of the nondementia subsample received an antipsychotic medication in the past week. Post-traumatic stress disorder, psychosis indicators, behavioral symptoms, anxiety medication with and without anxiety diagnosis, depression medication with and without depression diagnosis, and nurse staffing were among the strongest predictors of antipsychotic use in both subsamples. Simulation analyses showed decreased odds of receiving an antipsychotic in both subsamples when registered nurse hours matched the national average. Discussion Matching nurse staffing mix to the national average may improve antipsychotic use in nursing homes. Implications Knowledge of antipsychotic use risk factors use can inform care planning and staff education to minimize use of these medications in all but severe cases.

Call to action: APRNs in U.S. nursing homes to improve care and reduce costs.

BACKGROUND: Centers for Medicare and Medicaid Innovation Center sponsored the initiative to reduce avoidable hospitalizations among nursing facility residents. PURPOSE: Missouri Quality Initiative (MOQI) designed inter-professional model in nursing homes with advanced practice registered nurses (APRNs). METHOD: MOQI APRN model was implemented for 4 years in 16 nursing homes in a metro area of the Midwest. Hospitalizations were reduced (40% all-cause, 58% potentially avoidable), emergency room visits (54% all-cause, 65% potentially avoidable), Medicare expenditures for hospitalizations (34% all-cause, 45% potentially avoidable), and Medicare expenditures for emergency room visits (50% all-cause, 60% potentially avoidable) for long-stay nursing home residents. DISCUSSION: Success of the MOQI model reinforces decades of research demonstrating that care provided by APRNs is cost-effective, safe, and associated with positive health outcomes and patient satisfaction. CONCLUSION: Nursing homes can implement and benefit by hiring APRNs. However, changes in the Code of Federal Regulation (CFR 483.40) are necessary to improve patient access to care and encourage hiring APRNs in US nursing homes.

Psychotropic Alternatives to Antipsychotic Medications in Treating Dementia Behaviors: An Evidence-Based Practice Protocol.

Antipsychotic medications pose a significant risk to older adult patients with dementia and are frequently prescribed as first-line treatment for behaviors associated with dementia in skilled nursing facilities (SNFs). SNFs are often cited by the Centers for Medicare & Medicaid for inappropriate antipsychotic medication use. The purpose of the current article is to communicate an evidence-based practice (EBP) clinical protocol that can guide clinicians away from prescribing antipsychotic medications in the treatment of dementia behaviors. A literature review of 17 rigorous research studies was conducted to determine psychotropic risk and efficacy in treating dementia behaviors. An EBP clinical protocol establishing a hierarchy of psychotropic medications based on risk and efficacy was developed to guide clinicians away from the use of antipsychotic medications and toward the use of potentially safer and more efficacious psychotropic medications in dementia treatment while offering flexibility for clinical judgment. [Journal of Psychosocial Nursing and Mental Health Services, 54(10), 46-53.].